ABSTRACT
Study Objectives: Altered mental status (AMS) is frequently associated with poor outcomes across a wide spectrum of conditions including infections. This study aims to identify whether AMS in emergency department (ED) patients with COVID-19 is independently associated with in-hospital mortality. Methods: This was a retrospective multicenter cohort study. We included all patients with a positive SARS-CoV-2 PCR within 2 weeks of presentation, who were admitted from the ED of three hospitals in the greater Boston area between March and August 2020. The primary covariate of interest was ED AMS at ED arrival and the primary outcome was in-hospital mortality. The ED charts were abstracted for demographics, comorbid conditions, symptoms, laboratory testing, and radiology testing along with in-hospital outcomes. AMS was defined by documentation of changes in mental status from baseline. We used logistic regression modeling with backwards elimination to determine an adjusted estimate for the independent association of AMS with mortality. Results: We included 824 visits with 51% male, a mean age was 67.1 (SD 17.0) and 153 (18.6%) had AMS. There were 132 deaths for an overall mortality rate of 16.1%. Patients with AMS had in-hospital mortality of 38.2% (95% CI 30.4%-46.4%), compared to 11.1% (8.8%-13.7%) for patients without AMS (p<0.0001). After adjusting for potential confounders, visits by patients with AMS during their stay at the ED had 3.1 (95% CI, 2.1-5.9) times the odds of death compared to those without AMS. Conclusion: Among patients with COVID-19, AMS in the ED was associated with three-fold increase in mortality compared to patients without AMS.
ABSTRACT
Study Objectives: Sepsis is a common and deadly clinical syndrome that affects many patients presenting to the emergency department (ED). Sepsis-induced inflammation leads to abnormal coagulation. Additionally, one potential mechanism for abnormal coagulation and organ dysfunction in sepsis is injury to the endothelial glycocalyx;the glycocalyx contains heparans which are released during degradation and may cause mild coagulopathy. We hypothesize that coagulation abnormalities detected by bedside viscoelastic monitoring (VEM), such as thromboelastography, are associated with organ dysfunction and death (suggesting abnormal coagulation as a mediator). We further hypothesize that heparinase R-time, a VEM measurement that may detect glycocalyx degradation, will be associated with organ dysfunction. Methods: Patients >18 years old with a diagnosis of sepsis were recruited from an urban ED (∼55,000 visits per year) as part of an ongoing observational study of a convenience sample of patients. After informed consent was obtained, blood samples are to measure VEM. VEM measurements include the R time, K time, alpha angle, maximum amplitude (MA), lysis percent at 30 minutes (LY30), and change in R time with the addition of heparinase (ΔR). We also collect demographic information, comorbidities, sepsis severity, the information necessary to determine the Sequential Organ Failure Assessment (SOFA) score, and mortality data. We calculated descriptive statistics for VEM measurements, and Pearson correlations between VEM measurements and SOFA score on enrollment and on days 1-3. Results: We have enrolled 79 subjects thus far (study is ongoing). The baseline VEM parameters, expressed as median (IQR), are as follows: R, 5.3 minutes (4.2-6.4);K, 1.2 minutes (0.9-1.8);alpha angle, 72.0 degrees (65.7-75.8);MA, 68.3 millimeters (63.2-73.5);and LY30, 0.1 percent of maximum amplitude (0-1). The baseline ΔR is 0.4 minutes (IQR, 0.1-55). For patients enrolled to date, ΔR was correlated with day 1 SOFA score (r = -0.21, p < 0.03). Additionally, K was correlated with SOFA score on day 1 (0.22, p < 0.02) and day 2 (0.26, p < 0.03). Further results, delayed due to the impact of coronavirus on this project, will be available at the time of the Research Forum. Conclusion: It is feasible to obtain VEM measurements in patients with sepsis. Our ongoing work will recruit additional patients, measure syndecan-1 levels (a marker of glycocalyx degradation), determine illness severity scores (using Sequential Organ Failure Assessment scores) on days 0-3 and mortality outcomes, and determine whether syndecan-1 levels, VEM measurements, and patient outcome measurements are associated.